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In Canada and many other developed nations, it can be as safe as birth in a hospital for some women. But in the United States, it’s very dangerous compared with hospital birth. That isn’t because home birth is always more dangerous in all cases—it’s because home birth in the United States isn’t part of the medical system, and not all midwives are equal in terms of their medical education.

A 2016 study found that child mortality in Oregon—the place with the best records in the United States on this matter—was stunningly high compared to hospital birth.

Children were seven times more likely to die during planned home births, according to Amy Tuteur for The New York Times, and the perinatal death rate—the rate of death in the weeks just before and after birth—of babies for whom home birth was planned was three times that of hospital births.

“Could racial or economic differences, or poor prenatal care, explain this deadly difference between home births here and in Canada,” she asked? “No.”

The problem is that there are two types of midwives in the United States. The first, certified nurse midwives, called C.N.M.s, are perhaps the best-educated, best-trained midwives in the world, exceeding standards set by the International Confederation of Midwives. Their qualifications, similar to those of midwives in Canada, include a university degree in midwifery and extensive training in a hospital diagnosing and managing complications.

The other, certified professional midwives, or C.P.M.s, fall far short of international standards. One 2010 study of midwives published in The Journal of Perinatology found that home births attended by nurse midwives had double the neonatal mortality rate of hospital births attended by nurse midwives, while home births attended by C.P.M.s and other midwives had nearly four times that rate.

This second class of poorly trained midwives attend the majority of American home births. And yet they are legal in only 28 states; in the rest of the country, many practice outside the law.

But that isn't the only problem. Canadian midwifery is regulated at a federal level and midwives are not allowed to treat women who have serious medical conditions or are likely to have complicated births (like mothers carrying twins) at home. At the same time, she writes, “home birth in Canada is integrated into the obstetric system.”

The ACOG's opinion on home birth does not entirely write off the practice, but comes close. “Although the American College of Obstetricians and Gynecologists believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery,” the ACOG writes. “Importantly, women should be informed that several factors are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.”

“These factors include the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals,” the opinion reads.

However, the opinion’s authors cautioned that the kind of positive statistics associated with midwifery in other countries may not be possible to replicate in many parts of the United States, where integrated services between midwives, doctors and hospitals “are lacking.”

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About Kat Eschner

Kat Eschner is a freelance science and culture journalist based in Toronto.